CLINICAL APPROPRIATENESS GUIDELINES ADVANCED IMAGING Appropriate Use Criteria: Imaging of the Brain ARCHIVED MARCH 14, 2021 This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the AIM Specialty Health website at http://www.aimspecialtyhealth.com/ EFFECTIVE JANUARY 01, 2021 Proprietary ARCHIVED Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details. AIM Specialty Health disclaims any responsibility for the completeness or accuracy of the information contained herein. 8600 West Bryn Mawr Avenue Appropriate.Safe.Affordable South Tower – Suite 800 Chicago, IL 60631 © 2017 ©©©© 2021 AIM Specialty Health www.aimspecialtyhealth.com RBM06-300-0121.1 Imaging of the Brain Table of Contents Table of Contents ......................................................................................................................................................... 2 Description and Application of the Guidelines .......................................................................................................... 4 General Clinical Guideline ........................................................................................................................................... 5 Clinical Appropriateness Framework .................................................................................................................... 5 Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions .................................................... 5 Repeat Diagnostic Intervention .............................................................................................................................. 5 Repeat Therapeutic Intervention ............................................................................................................................ 6 Imaging of the Brain .................................................................................................................................................... 7 General Information/Overview ................................................................................................................................ 7 Scope .................................................................................................................................................................... 7 Technology Considerations ................................................................................................................................... 7 Definitions .............................................................................................................................................................. 8 Clinical Indications ...................................................................................................................................................... 9 Congenital and Developmental Conditions ........................................................................................................... 9 Developmental delay (Pediatric only) .................................................................................................................... 9 Congenital anomalies .......................................................................................................................................... 10 Infectious Conditions ............................................................................................................................................ 10 Infectious conditions – not otherwise specified .................................................................................................... 10 Inflammatory Conditions....................................................................................................................................... 11 Multiple sclerosis (MS) and other white matter diseases ..................................................................................... 11 Inflammatory conditions – not otherwise specified .............................................................................................. 12 Neurodegenerative Conditions ............................................................................................................................. 12 Movement disorders (Adult only) ......................................................................................................................... 12 Neurocognitive disorders (Adult only) .................................................................................................................. 13 Trauma .................................................................................................................................................................... 14 Trauma ................................................................................................................................................................ 14 Tumor or Neoplasm ............................................................................................................................................... 16 Acoustic neuroma ................................................................................................................................................ 16 Pituitary adenoma ................................ARCHIVED............................................................................................................... 17 Tumor – not otherwise specified .......................................................................................................................... 17 Miscellaneous Conditions..................................................................................................................................... 18 Bell’s palsy (peripheral facial nerve palsy)........................................................................................................... 18 Hematoma or hemorrhage – intracranial or extracranial ..................................................................................... 18 Horner’s syndrome .............................................................................................................................................. 18 Hydrocephalus/ventricular assessment ............................................................................................................... 19 Neurocutaneous disorders .................................................................................................................................. 19 Pseudotumor cerebri ........................................................................................................................................... 20 Seizure disorder and epilepsy ............................................................................................................................. 20 Spontaneous intracranial hypotension (SIH) ....................................................................................................... 22 Stroke or transient ischemic attack (TIA) ............................................................................................................. 22 Copyright © 2021. AIM Specialty Health. All Rights Reserved. 2 Imaging of the Brain Trigeminal neuralgia and persistent idiopathic facial pain (Adult only) ................................................................ 23 Perioperative/Periprocedural Imaging ................................................................................................................. 23 Lumbar puncture risk assessment ....................................................................................................................... 23 Signs and Symptoms ............................................................................................................................................ 23 Abnormality on neurologic exam ......................................................................................................................... 23 Ataxia .................................................................................................................................................................. 24 Dizziness or vertigo ............................................................................................................................................. 24 Headache ............................................................................................................................................................ 25 Hearing loss ........................................................................................................................................................ 27 Mental status change and encephalopathy ......................................................................................................... 28 Papilledema ......................................................................................................................................................... 28 Syncope .............................................................................................................................................................. 28 Tinnitus ................................................................................................................................................................ 28 Visual disturbance ..............................................................................................................................................